A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
Sit at or below the client's eye level during feedings.
Instruct the client to lift her chin when swallowing.
Talk with the client during her feeding.
Discourage the client from coughing during feedings.
The Correct Answer is A
Rationale:
A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.
B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.
C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.
D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Remove the cap and place it sterile-side up on a clean surface: Placing the cap with the sterile side up can contaminate the inside of the cap and potentially the solution. The cap should be placed sterile-side down or on a clean, nonsterile surface to prevent contamination of the sterile solution.
B. Hold the bottle in the center of the sterile field when pouring the solution: Placing the bottle over the sterile field risks contaminating it if any part of the bottle or solution touches the sterile area. The bottle should be held outside the sterile field and poured carefully to maintain sterility.
C. Place sterile gauze over areas of spilled solution within the sterile field: Once a sterile field is contaminated by spilled solution, it cannot be safely salvaged by placing sterile gauze over it. Any contamination requires replacement of the affected items to maintain aseptic technique.
D. Hold the irrigation solution bottle with the label facing away from the palm of the hand: This technique prevents the solution from contacting the label, which could obscure important information or lead to accidental contamination. Proper handling preserves sterility while ensuring the label remains legible for verification.
Correct Answer is C
Explanation
Rationale:
A. Remove the client's catheter: Removing the catheter could allow more air to enter the circulation and worsen the embolism. The priority is to prevent further air entry while stabilizing the client, not immediate removal of the line.
B. Prepare the client for chest tube insertion: Chest tubes are used for pneumothorax or pleural effusions, not for treating an air embolism. Immediate positioning and oxygen therapy are the primary interventions.
C. Place the client in a left-lateral Trendelenburg position: Positioning the client in the left-lateral Trendelenburg (head down, left side down) traps air in the right atrium and prevents it from entering the pulmonary circulation, reducing cardiovascular compromise. This is the recommended first intervention for a suspected air embolism.
D. Instruct the client to perform the Valsalva maneuver: Performing the Valsalva maneuver increases intrathoracic pressure and may temporarily help, but it is not the first priority. Proper positioning and immediate oxygen administration are more critical to prevent complications.
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